Community and lay health workers are individuals who provide basic health services within their communities but do not have formal professional or paraprofessional certification. They may be volunteers or salaried workers trained to perform specific health-related tasks, such as administering oral misoprostol for PPH prevention, under supervision and in line with national policies and protocols. Their role is often critical in settings with limited access to skilled health personnel

• The GDG noted that evidence on the efficacy of misoprostol was largely derived from trials involving women giving birth vaginally. However, misoprostol has been used for women giving birth via caesarean section in a few trials. The GDG emphasized that there may be a need for the use of alternative routes of administration, such as rectal for women under general anaesthesia for caesarean section, or rectal or sublingual for women under spinal anaesthesia for caesarean section.
• The GDG advised that all women are to be provided with information – ideally during antenatal care – on the need for an effective uterotonic to prevent PPH.
• The GDG noted that previous trials have largely used 600-μg or 400-μg doses of misoprostol. While there is currently no clear evidence to demonstrate that a 600-μg dose provides greater efficacy over a 400-μg dose, there is some evidence that higher doses are likely to have worse side-effects.
• To maximize efficacy, misoprostol is best given immediately (preferably within 1 minute) after the birth of the baby or babies. Administration for the prevention of PPH need not impede the delaying of cord clamping.
• Although different routes of administration (i.e. oral, buccal, sublingual, rectal) have been evaluated in trials of misoprostol for PPH prevention, the recommended route of administration is based on the consideration of a woman’s preferences for oral over rectal administration
• Skilled health personnel who provide care during childbirth are defined by the 2018 joint statement by WHO, the United Nations Population Fund, the United Nations Children’s Fund (UNICEF), the ICM, the International Council of Nurses (ICN), FIGO and the International Pediatric Association (IPA) as competent maternal and newborn health (MNH) professionals who hold identified MNH competencies; are educated, trained and regulated to national and international standards; and are supported within an enabling environment in the health system (47).
• The GDG acknowledged that there are settings where skilled health personnel may not be present, or where they may not have been trained to administer injectable uterotonics appropriately. In these settings, oral misoprostol would be the preferred uterotonic.
• Community and lay health workers should receive appropriate training and supervision to safely administer misoprostol for PPH prevention, including education on correct dosing, timing, potential side-effects and referral procedures in the event of complications.
• The availability of misoprostol at the community level should be supported by consistent supply chain management and integration into national essential medicines lists and procurement plans.
• Engagement with women, families and community leaders is important to promote awareness, acceptability and trust in community-based PPH prevention efforts involving misoprostol.
• Where feasible, implementation of misoprostol by lay health workers should be accompanied by mechanisms for monitoring and evaluation to assess safety, coverage and effectiveness.